Compilation of the Social Security Laws

SCOPE OF BENEFITS

Sec. 1832. [42 U.S.C. 1395k](a) The benefits provided
to an individual by the insurance program established by this part
shall consist of—

(1) entitlement to
have payment made to him or on his behalf (subject to the provisions
of this part) for medical and other health services, except those
described in subparagraphs (B) and (D) of paragraph (2) and subparagraphs
(E) and (F) of section 1842(b)(6); and

(2) entitlement to
have payment made on his behalf (subject to the provisions of this
part) for—

(A) home health
services (other than items described in subparagraph (G) or subparagraph
(I));

(B) medical and
other health services (other than items described in subparagraph
(G) or subparagraph (I)) furnished by a provider of services or by
others under arrangement with them made by a provider of services,
excluding—

(II) a physician
to a patient in a hospital which has a teaching program approved as
specified in paragraph (6) of section 1861(b) (including services in conjunction
with the teaching programs of such hospital whether or not such patient
is an inpatient of such hospital) where the conditions specified in
paragraph (7) of such section are met,

(ii) services for
which payment may be made pursuant to section 1835(b)(2),

(iv) services of
a nurse practitioner or clinical nurse specialist but only if no facility
or other provider charges or is paid any amounts with respect to the
furnishing of such services; and

(C) outpatient
physical therapy services (other than services to which the second
sentence of section 1861(p) applies), outpatient occupational therapy services
(other than services to which such sentence applies through the operation
of section 1861(g), and outpatient speech-language pathology services (other than services
to which the second sentence of section 1861(p) applies through the application
of section 1861(ll)(2));

(F) facility
services furnished in connection with surgical procedures specified
by the Secretary—

(i) pursuant to section 1833(i)(1)(A) and
performed in an ambulatory surgical center (which meets health, safety,
and other standards specified by the Secretary in regulations) if
the center has an agreement in effect with the Secretary by which
the center agrees to accept the standard overhead amount determined
under section 1833(i)(2)(A) as full payment for such services (including intraocular lens in
cases described in section 1833(i)(2)(A)(iii)) and to accept
an assignment described in section 1842(b)(3)(B)(ii) with respect
to payment for all such services (including intraocular lens in cases
described in section 1833(i)(2)(A)(iii)) furnished
by the center to individuals enrolled under this part, or

(ii) pursuant to
section 1833(i)(1)(B) and performed by a physician, described in paragraph (1), (2), or
(3) of section 1861(r), in his office, if the Secretary has determined that—

(I) a quality
improvement[53] organization (having
a contract with the Secretary under part B of title XI of this Act)
is willing, able, and has agreed to carry out a review (on a sample
or other reasonable basis) of the physician’s performing such
procedures in the physician’s office,

(II) the particular
physician involved has agreed to make available to such organization
such records as the Secretary determines to be necessary to carry
out the review, and

(III) the
physician is authorized to perform the procedure in a hospital located
in the area in which the office is located,

and if the physician agrees to accept the standard overhead
amount determined under section 1833(i)(2)(B) as full payment for
such services and to accept payment on an assignment-related basis
with respect to payment for all services (including all pre-and post-operative
services) described in paragraphs (1) and (2)(A) of section 1861(s) and furnished
in connection with such surgical procedure to individuals enrolled
under this part;

(G) covered items
(described in section 1834(a)(13)) furnished by a provider of services or by others
under arrangements with them made by a provider of services;

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